Impact of a Free Health Care Policy in the Democratic Republic of the Congo During an Ebola Outbreak: An Interrupted Time-Series Analysis

Abstract

Background: During past outbreaks of Ebola Virus Disease (EVD) and other infectious diseases, health service utilization declined among the general public, delaying health seeking behavior and affecting population health. In 2018, the Democratic Republic of Congo (DRC) announced a free health care policy during an EVD outbreak in affected and neighboring areas. We evaluated the impact of this policy on health service utilization. Methods: Using monthly data from the national Health Management Information System from January 2017 to January 2019, we examined rates of the use of nine health services at primary health facilities: total visits; first and fourth antenatal care visits; institutional deliveries; postnatal care visits; DTP vaccinations; and visits for uncomplicated malaria, pneumonia, and diarrhea. We used controlled interrupted time series analysis with a mixed effects model to estimate changes in the rates of services use during the policy (June -September 2018) and afterward. Findings: Use of most services increased, including EVD affected zones. Total visits and visits for pneumonia and diarrhea increased more than two-fold relative to the control areas (p<0·001), while institutional deliveries and first antenatal care increased between 20-50% (p<0·01). Visits for DTP, fourth antenatal care visits and postnatal care visits were not significantly affected. Most increases did not persist after the policy ended. Interpretation: The free care policy was effective at rapidly increasing the use of health services, but this effect was not sustained post-FCP. Such policies may mitigate the impact of infectious disease outbreaks on health service utilization. Funding Statement: This project received funding from the Rapid Research Fund for Ebola supported by the International Development Research Centre, Social Sciences and Humanities Research Council, and Canadian Institutes of Health Research, and AXA Research Fund. Dr. Law received salary support through a Canada Research Chair and a Michael Smith Foundation for Health Research Scholar Award. Dr. Grepin also received salary support through a Canada Research Chair. Declaration of Interests: Dr. Law has consulted for Health Canada, the Health Employees’ Union, the Conference Board of Canada, and provided expert witness testimony for the Attorney General of Canada. All other authors report no potential conflicts of interest. Ethics Approval Statement: The research protocol was approved by the Ethics Committees at Wilfrid Laurier University and Kinshasa School of Public Health.